Basic Information
| Provider Information | |||||||||
| NPI: | 1639258130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE PHYSICIAN GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170257 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 BOTHELL EVERETT HWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982086642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253165150 | ||||||||
| FaxNumber: | 4253165153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | BEEGLE | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4253165470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 7095367 | 05 | WA | MEDICAID |